HIV Treatment Strategies Across Central, Eastern and Southeastern Europe

New Times, Old Problems

Antonios Papadopoulos; Konstantinos Thomas; Konstantinos Protopapas; Sergii Antonyak; Josip Begovac; Gordana Dragovic; Deniz Gökengin; Kersti Aimla; Valbon Krasniqi; Botond Lakatos; Mariana Mardarescu; Raimonda Matulionyte; Velida Mulabdic; Cristiana Oprea; Aleksandr Panteleev; Dalibor Sedláček; Lubomir Sojak; Agata Skrzat-Klapaczyńska; Anna Vassilenko; Nina Yancheva; Oleg Yurin; Andrzej Horban; Justyna D. Kowalska


HIV Medicine. 2023;24(4):462-470. 

In This Article

Abstract and Introduction


Introduction: In the last decade, substantial differences in the epidemiology of, antiretroviral therapy (ART) for, cascade of care in and support to people with HIV in vulnerable populations have been observed between countries in Western Europe, Central Europe (CE) and Eastern Europe (EE). The aim of this study was to use a survey to explore whether ART availability and therapies have evolved in CE and EE according to European guidelines.

Methods: The Euroguidelines in Central and Eastern Europe (ECEE) Network Group conducted two identical multicentre cross-sectional online surveys in 2019 and 2021 concerning the availability and use of antiretroviral drugs (boosted protease inhibitors [bPIs], integrase inhibitors [INSTIs] and nucleoside reverse transcriptase inhibitors [NRTIs]), the introduction of a rapid ART start strategy and the use of two-drug regimens (2DRs) for starting or switching ART. We also investigated barriers to the implementation of these strategies in each region.

Results: In total, 18 centres participated in the study: four from CE, six from EE and eight from Southeastern Europe (SEE). Between those 2 years, older PIs were less frequently used and darunavir-based regimens were the main PIs (83%); bictegravir-based and tenofovir alafenamide-based regimens were introduced in CE and SEE but not in EE. The COVID-19 pandemic did not significantly interrupt delivery of ART in most centres. Two-thirds of centres adopted a rapid ART start strategy, mainly in pregnant women and to improve linkage of care in vulnerable populations. The main obstacle to rapid ART start was that national guidelines in several countries from all three regions did not support such as strategy or required laboratory tests first; an INSTI/NRTI combination was the most commonly prescribed regimen (75%) and was exclusively prescribed in SEE. 2DRs are increasingly used for starting or switching ART (58%), and an INSTI/NRTI was the preferred regimen (75%) in all regions and exclusively prescribed in SEE, whereas the use of bPIs declined. Metabolic disorders and adverse drug reactions were the main reasons for starting a 2DR; in the second survey, HIV RNA <500 000 c/ml and high cluster of differentiation (CD)-4 count emerged as additional important reasons.

Conclusions: In just 2 years and in spite of the emergence of the COVID-19 pandemic, significant achievements concerning ART availability and strategies have occurred in CE, EE and SEE that facilitate the harmonization of those strategies with the European AIDS Clinical Society guidelines. Few exceptions exist, especially in EE. Continuous effort is needed to overcome various obstacles (administrative, financial, national guideline restrictions) in some countries.


In the 40 years since the first cases of acquired immune deficiency syndrome (AIDS) were reported, remarkable progress has been made in the global response to the human immunodeficiency virus (HIV) epidemic. This progress has been achieved through the implementation of HIV prevention programmes, efficient treatment of opportunistic infections and viral hepatitis, scale-up administration of combination antiretroviral therapy (ART) for HIV treatment and prevention and extensive HIV testing and counselling.[1] In 2014, the Joint National Program on HIV/AIDS (UNAIDS) established the global 90-90-90 targets, that is, 90% of all people living with HIV to be diagnosed, 90% of them to receive ART and 90% of the latter to achieve viral suppression by 2020;[2] these targets were recently updated to 95-95-95.[3] These targets have been reached in some developed countries, but significant inequalities exist in many parts of the world.[1]

The HIV situation in Europe is diverse.[4] In the European AIDS Clinical Society (EACS) Standard of Care Meeting in Brussels in 2016, it was highlighted that ART access in Eastern Europe (EE) was unacceptably low (20%–47%) across countries and that rates of viral suppression were very low rates because of the limited availability of treatment, criminalization and exclusion of vulnerable population at risk as stated below.[5] ART coverage was better (60%–69%) in Central Europe (CE). In 2018, an online survey disseminated by the European Centre for Disease Prevention and Control in 52 European and Central Asian countries revealed that, overall, 80% of people living with HIV were diagnosed, of whom 64% received ART and 86% of those treated were virally suppressed, but subregional outcomes varied.[6] The 90-90-90 corresponding results were 87-91-93 in the West, 83-75-75 in CE and 76%-46%-78% in EE. Likewise, the Euroguidelines in Central and Eastern Europe (ECEE) Conference in Warsaw in 2016, held under the auspices of EACS, highlighted that the HIV situation significantly differed in CE and EE from that in Western Europe in many respects, including epidemiology, mode of transmission, testing, ART (availability of drugs, treatment initiation, various regimens), cascade of care and organization and treatment access for vulnerable populations (e.g. people with HIV and viral hepatitis, people who inject drugs [PWID], migrants and prisoners).[7] Another online survey report of the ECEE Network Group noted that the percentage of people virologically suppressed while on ART was 70%–95% in CE, 32%–95% in EE and 62%–97% in Southeastern Europe (SEE).[8]

These differences in the care of people living with HIV can be accounted for by several factors, including that the newest antiretrovirals or new fixed-dose combinations (FDCs) are not available or are available with some restrictions in some areas of CEE, there are limitations in first-line ART choice in other countries and that people living with HIV exhibit poor adherence to therapy and are frequently lost to follow-up because of stigma and social discrimination.[5,7,9]

The EACS guidelines have also contained novel strategies, in concordance with other national and international guidelines, including rapid ART start and two-drug regimens (2DRs) for starting or switching ART.[10–12] The differences in the care of people living with HIV in CE make EACS guidelines difficult to implement.[7]

The aim of our study was to use online surveys in 2019 and 2021 to ascertain whether recent advances in the management of HIV infections in CE, EE and SEE had an impact on ART availability and the introduction of novel therapeutic strategies according to EACS guidelines in daily practice.